366425024-4-3-2025-56-AS-EMAN-DG2SZG-20250424141906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 04/03/2025
Date Signed: 04/03/2025 01:58:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2025 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20250327105844

FACILITY NAME:	CHINO HILLS SENIOR LIVING		FACILITY NUMBER:	366425024
ADMINISTRATOR:	JULIE (OLMEDO) DION		FACILITY TYPE:	740
ADDRESS:	6500 BUTTERFIELD RANCH RD		TELEPHONE:	(909) 606-2553
CITY:	CHINO HILLS	STATE: CA	ZIP CODE:	91709
CAPACITY:	94	CENSUS: 68	DATE:	04/03/2025
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Lizeth (Lisa) Gomez		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.
Staff left resident in a soiled diaper for a long period of time.
Staff did not clean resident's bedroom floor.
Staff did not safeguard resident's personal items.
Staff do not ensure that resident is provided with clean clothng as needed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Business Office Manager Lizeth (Lisa) Gomez and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Resident sustained unexplained injuries while in care. Regarding the allegation “Resident sustained unexplained injuries while in care” LPA conducted an interview with Resident #1 regarding the allegation and Resident #1 informed LPA that the injurie[s] on R#1 (L) shin and knee are old injuries that R#1 sustained during an accidental fall. Resident #1 denied abuse and informed LPA that injuries sustained are old injuries. LPA conducted a review of records and discovered through facilities (Unusual Incident/Injury Reports), that Resident #1 has been found on the floor sitting next to the bed or wheelchair; Resident#1 denied any falls and stated that Resident had crawled out of bed. LPA conducted an interview with Facility Resident Service Director who informed LPA that no falls have been reported for Resident #1 however, Resident #1 has been displaying behaviors on different occurrences (3/19/2025 and 4/01/2025), throughout the day where resident is found sitting on the floor and denying falls.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20250327105844

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHINO HILLS SENIOR LIVING	FACILITY NUMBER: 366425024
	VISIT DATE: 04/03/2025

NARRATIVE

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Service Director informed LPA that no injuries were observed on R#1 during (3/19/2025 and 4/01/2025) incidents.
Second allegation: Staff left resident in a soiled diaper for a long period of time. Regarding the allegation “Staff left resident in a soiled diaper for a long period of time” LPA conducted an interview with Resident #1 regarding the allegation, Resident #1 informed LPA that caregivers change resident diaper/pull-up when needed. LPA asked resident if staff has left resident on a soiled diaper for a long period of time Resident#1 informed LPA that during the times resident does not want to be bothered is when resident diaper/pull-up does not get changed. LPA conducted interview with Staff #1 and Staff #2 and both informed LPA that on several occasions Resident #1 has refused care. LPA conducted a review of records and discovered that on: (3/26, 3/27, 3/28, 3/29, 3/30, and 4/2), Resident #1 has refused care.

Third allegation: Staff did not clean resident's bedroom floor. Regarding the allegation “Staff did not clean resident's bedroom floor.” LPA conducted a walkthrough of Resident #1 room and observed floors to be clean and free from biohazard (fecal matter), or any waste that can pose as a health risk to Resident #1. In addition, Resident #1 room was free of odors and LPA observed R#1 room to be free from any bodily fluids. LPA conducted record review and discovered through housekeeping schedule that Resident #1 room gets clean once a week every Sunday.

Fourth allegation: Staff did not safeguard resident's personal items. Regarding the allegation “Staff did not safeguard resident's personal items” LPA conducted an interview with Resident #1 regarding the allegation LPA asked Resident #1 if resident was able to list and describe the personal items that went missing. Resident #1 was not able to list or describe the personal items that went missing. Resident #1 informed LPA that Resident was not sure about the items that went missing.

Fifth allegation: Staff do not ensure that resident is provided with clean clothing as needed. Regarding the allegation “Staff do not ensure that resident is provided with clean clothing as needed.” LPA conducted an interview with Resident #1 regarding the allegation Resident #1 informed LPA the resident’s sister picks-up residents’ laundry and washes Resident #1 Laundry. Resident #1 informed LPA that resident sister has not picked-up resident’s clothes to be washed. LPA conducted a record review and discovered that on 3/28/25 Resident #1 responsible party refused to take Resident #1 laundry.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20250327105844

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHINO HILLS SENIOR LIVING	FACILITY NUMBER: 366425024
	VISIT DATE: 04/03/2025

NARRATIVE

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During review of record LPA discovered that on 12/20/2023 facility provided a service update to all residents along with resident’s responsible parties informing that as of March 1, 2024, facility will be providing two laundry service options: (1 load per week=$100/month and 2 loads per week=$200/month), Staff #1 informed LPA that laundry services are not free and that its an additional charge. During further review LPA discovered that Resident #1 was issued a 30-day notice due to non-payment and having an outstanding balance of $17,140.00. Staff #1 informed LPA that Resident #1 outstanding balance also includes non-payments for laundry services. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated.

Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Business Office Manager Lizeth (Lisa) Gomez at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC9099 (FAS) - (06/04)

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